Lit Matters #1: Can ECG Predict Badness After Cardiac Arrest?

A post-ROSC 12-lead ECG without ST elevation is better for risk stratification than for finding an acute culprit lesion after out-of-hospital cardiac arrest. In TOMAHAWK patients, ECG abnormalities tracked with 30-day mortality, while prediction of significant coronary disease was essentially no better than chance.

Post-ROSC ECG After OHCA

• Prognostic not diagnostic signal: After OHCA without ST elevation, the standardized 12-lead ECG helped identify patients at higher 30-day mortality risk but did not reliably identify who had significant coronary lesions.
• Poor lesion discrimination: Across measured ECG patterns, prediction of significant coronary lesions was essentially coin-flip performance, with AUCs around 0.5 rather than a clinically useful discriminator.
• Right bundle branch block: Complete right bundle branch block stood out as a mortality red flag, with roughly 2.5-fold higher odds of 30-day death after resuscitated OHCA without ST elevation.
• Atrial fibrillation association: Atrial fibrillation or flutter on the post-ROSC ECG also carried prognostic weight, with about a twofold increase in 30-day mortality risk in this cohort.
• Intrinsicoid deflection clue: In RBBB, prolonged intrinsicoid deflection added risk signal beyond a routine abnormal tracing and may be an underrecognized marker of badness. We get into why that pattern matters in the episode.
• Cath lab clinical trigger: A substantial minority still had significant coronary disease, with 40% undergoing PCI, so progressive or refractory shock remains a practical reason to push toward urgent diagnostic angiography.